Transcatheter Closure of a Mitral Valve Paravalvular Leak in an Infant

Abstract

Mitral valve replacement, which is a relatively rare procedure in young children, can be complicated by paravalvular leaks (PVLs). Here, we report the first successful percutaneous treatment of a PVL in an infant. The patient was a 7-month-old, 6 kg boy with a history of Shone’s complex after aortic arch reconstruction and balloon valvuloplasty of the mitral valve. Due to severe mitral insufficiency, he underwent mitral valve replacement with a 16-mm Medtronic open-pivot AP 360 mechanical aortic valve in the supra-annular mitral position at 5 months of age. He developed a posterior PVL post-operatively with persistent hemolysis requiring repeated transfusions. Medical therapy with pentoxifylline failed. Thus, 2 months post-operatively, he was referred for percutaneous cardiac catheterization for PVL closure. Transesophageal echocardiography (TEE) identified a small PVL between the mouth of the left atrial appendage and the left upper pulmonary vein. A trans-septal approach was utilized. Using a Cobra catheter, a 0.018” floppy wire was advanced from the venous sheath through the leak and into the ascending aorta, where it was snared by a multisnare introduced from the arterial sheath. A 4-mm Amplatzer vascular plug II was then positioned anterogradely and successfully deployed in the tract. No significant leak was visualized by angiography or TEE, and the child’s hemolysis subsided. Our case demonstrates that device closure of mitral valve PVL in a very small child is technically feasible and may obviate repeat surgery.